Provider Demographics
NPI:1851397418
Name:RIVERA, LUZVIMINDA C (MD)
Entity Type:Individual
Prefix:
First Name:LUZVIMINDA
Middle Name:C
Last Name:RIVERA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26190 OUTER DR
Mailing Address - Street 2:
Mailing Address - City:LINCOLN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48146-2084
Mailing Address - Country:US
Mailing Address - Phone:313-386-8330
Mailing Address - Fax:313-388-5667
Practice Address - Street 1:26190 OUTER DR
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:MI
Practice Address - Zip Code:48146-2084
Practice Address - Country:US
Practice Address - Phone:313-386-8330
Practice Address - Fax:313-388-5667
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-28
Last Update Date:2009-12-01
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-24
Provider Licenses
StateLicense IDTaxonomies
MI033619207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2604745 TYPE 10Medicaid
MIB43788Medicare UPIN
MI08265449111Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER